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The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Redness and edema noted at the incision site.
- B. Apical heart rate of 100 to 110 beats/minute.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 0 to 10.
Correct Answer: C
Rationale: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.
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A patient experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?
- A. Headache rated at 0 on 0 to 10 scale.
- B. Oxygen saturation level of 99%.
- C. Ambulates easily without vertigo.
- D. Blood pressure of 120/80 mm Hg.
Correct Answer: C
Rationale: Ambulating easily without vertigo indicates the antihistamine is effective, as it reduces fluid buildup in the inner ear, relieving vertigo, a common symptom of Ménière's disease.
After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?
- A. Make a referral for social services at home.
- B. Continue to limit daily fluid intake to 500 mL.
- C. Begin preparing the client for discharge home.
- D. Recommend strict intake and output monitoring.
Correct Answer: C
Rationale: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.
A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?
- A. Restriction of caloric intake.
- B. Fewer fingerstick glucose checks.
- C. Higher doses of insulin.
- D. Increased oral fluid intake.
Correct Answer: C
Rationale: Higher doses of insulin are needed to overcome increased insulin resistance caused by the infection and stress hormones, preventing hyperglycemia and ketoacidosis.
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?
- A. Measure capillary glucose level.
- B. Encourage ambulation in the room.
- C. Monitor for bloody diarrheal stools.
- D. Obtain vital sign measurements.
Correct Answer: D
Rationale: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness, indicating peritonitis, a serious complication of IBD. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, guiding appropriate interventions and treatments.
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells, due to HIV infection, impair cellular immunity, leading to susceptibility to opportunistic infections like Pneumocystis jiroveci pneumonia.